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Health Insurance – (12 February 2017)

The writer was medical director of the Washington D.C. Medicaid Programme.

Published in Dawn, February 12th, 2017

“ACCESS to quality healthcare services is the inherent right of all Pakistanis,” said Prime Minister Nawaz Sharif, as have those before him. The proclamations were followed, as is this one, with the same ad hoc piecemeal, donor-driven individual schemes to build a service that last only as long as donor funding.The Prime Minister’s National Health Programme, the “social welfare scheme” for the “underprivileged” offering health cards to be redeemed for hospitalisation is another example of ad hocism, government desperation, and general magical thinking.

Lofty objectives are good. It is their translation into reality where lies the rub. Past experience and analyses tell us the reasons for failure of donor-funded efforts to build viable and sustained services. The larger issues are inherent to deficiencies in government institutions — in governance, poor human resource, lack of accountability, and lack of oversight. These deficiencies, which are a hurdle to even the full utilisation of government’s own health budget, are for the government to fix and cannot be bought by donor money. Provincial governments need to face this reality, the federal government needs to ensure that something is done about it.

________________________________________Why build a parallel health system for the poor?________________________________________

There are three levels of Sehat cards — the highest level ‘priority package’ is up to Rs250,000 per person, per year, for a list of complex conditions such as cancer. In The Financial Burden of Cancer: Estimates from Patients Undergoing Cancer Care in a Tertiary-Care Hospital, 2012; the authors report that the mean and median monthly cost of cancer care in Pakistan was $1093.13 and $946.42 respectively. And the overall average duration for all cancers was 6.7 months. For breast cancer it was 7.8 months and for head and neck cancer 5.04 months.

In addition to direct costs for cancer treatment, there are related costs of cancer care that can require hospitalisation and treatment running into the thousands. For example in a US-based study, severe mucositis/pharyngitis occurred in 70.1 per cent of patients treated for head and neck cancer and in 37.5pc of patients with lung cancer during radio-chemotherapy, requiring extended hospitalisation and treatment.

Rs.250, 000 is not going to go far.

The health (Sehat) cards are to be redeemed at 34 general hospitals in the private sector and 10 referral hospitals. One is puzzled by the rationale of the recommendation to use private hospitals.Why are reimbursements promised to for-profit hospitals, whose fee structure is of their own making, and not under the government’s control? Private hospitals, which are not monitored for consistent quality by any government agency? Which are answerable only to their board of directors? What prevents the private hospital from refusing service once the Rs250,000 runs out in two months, while the cancer lasts for six? How is that risk covered?

At the same time, there is the government’s already existing impressive network of healthcare facilities, including 965 secondary- and tertiary-care hospitals, in every district, including in large cities. These public-sector hospitals are already set up as a ‘welfare system’, receiving funding — close to 70pc of the national health budget. Their mandate is to provide comprehensive health services, including care for cancer and heart disease, to poor people without charge. And there is no need to bother with a card.So what is the need to build a parallel system for poor people?

Even if there is an imperative to launch this national programme, one would think that Mr Sharif’s technical advisers would advise him to use this opportunity to think through a comprehensive strategy that includes the major health system reforms (funded by the World Bank and Britain) going on in Punjab and Sindh. Part of that reform is strengthening the public system to make it responsive to the needs of “poor citizens” (as articulated by the Punjab chief minister in 2013). What would be better than to avoid overlap and coordinate these two efforts since one of the donors (WB) is common to both efforts?It is true that most of the public-sector hospitals are non-functional and unusable, forcing people to seek care in private hospitals. The deficiencies in public-sector hospitals are the responsibility of the provincial ministry of health and for them to fix. The National Health Programme, if it does nothing else, could be used as an opportunity to start this process.

Health insurance programmes are complex, requiring coordination and integrated support systems. These function best in the context of a stable overall service delivery system. Without that, this health card scheme will last only as long as donor funding. The prime minister’s technical advisors would be wise to not waste this opportunity.

The writer was medical director of the Washington D.C. Medicaid Programme.